My goal as Secretary is to make the Department of Veterans Affairs the No. 1 federal agency for customer service. You can’t be No. 1 in customer service without talking to your customers, so I’m taking every opportunity to hear from Veterans and answer their questions — in town-hall meetings, at VSO conventions, and in personal conversations with Veterans’ representatives and VSO leaders.
Recently, I had the opportunity to meet Ron Brown, President of the National Gulf War Resource Center. Ron and I served in the same company of the 82d Airborne Division: Charlie Company, 1/504th. I was just a few years ahead of him.
Ron’s a Veteran of Operation Just Cause and Operations Desert Shield and Desert Storm. He struggled for years to have his claim of Gulf War-related disability approved by VA and has since dedicated his life to helping other Veterans with the same difficulty.
He asked if I would answer a few questions about VA’s treatment of Veterans with Gulf War illness, and of course I jumped at the chance. To make the answers available to Veterans as soon as possible, we decided to post full responses to them here on this blog.
Ron Brown: After many years of Desert Storm Veterans being told Gulf War Illness was psychological, and with research finally showing it to be physiological, what is the VA’s official statement and stance on Gulf War Illness in 2015?
Secretary Bob McDonald: VA physicians have been treating Gulf War Veterans for many years with symptoms like fatigue, chronic pain, cognitive/memory problems, respiratory problems, digestive difficulties, skin rashes and sleep problems. Some of these symptoms are due to well-known, diagnosable medical conditions, but 25 to 30 percent of Gulf War Veterans exhibit a chronic multisymptom illness (CMI), which has been called “Gulf War illness.”
One of the difficulties with diagnosing and treating this condition is that it has been defined in many different ways. To address that problem, we asked the Institute of Medicine (IOM), known as the National Academy of Medicine as of 7/1/15, to study the issues and recommend alternatives. Last year, the IOM released its report, recommending that we use the “Kansas” and Centers for Disease Control and Prevention (CDC) definitions for the condition. VA has concurred with that recommendation and encourages VA researchers to use these definitions.
The IOM also recommended that we use the term “Gulf War illness” instead of CMI, but CMI appears so frequently in literature on the subject that we don’t want to abandon it completely just yet. We now prefer the term “Gulf War illness presenting as chronic multisymptom illness.” We expect that the terminology could change again as our understanding of the illness evolves.
Brown: What can be done to ensure that all VA primary care providers (PCP) are properly trained in the specific issues that relate to treating Desert Storm Veterans?
McDonald: We are currently developing a deployment health roadmap and toolkit to ensure that Veterans’ health concerns are effectively addressed by Patient Aligned Care Teams (PACT). The toolkit will include educational materials and a Clinical Practice Guideline (CPG) for Gulf War CMI Veterans, their families and the clinical team. Both the roadmap and the toolkit will be available to all clinical teams on the PACT Primary Care website. They will also be part of annual PACT online education highlighting the key knowledge areas for the management of post deployment health, including military service-related environmental exposures and CMI and use of the CMI CPG.
The deployment health roadmap could also be incorporated into the educational efforts of many other programs such the Post-Deployment Integrated Care Initiative (PDICI), the War Related Illness and Injury Study Centers (WRIISC), the Office of Public Health, the Employee Education System’s Gulf War Veteran’s Health Initiative and the VA eHealth University.
Brown: Many Veterans contact the NGWRC about how they must bring in information on issues concerning Gulf War Illness to their PCPs. We also hear from many Veterans that their PCPs have never heard of VA’s War Related Illness and Injury Study Centers (WRIISC), which specialize in toxic and environmental exposures. How do we make sure that all PCPs are aware that the WRIISC is out there and available for Veterans who have suffered toxic exposure from their service?
McDonald: The WRIISCs publish and distribute a newsletter, WRIISC Advantage, three times annually to more than 4,500 individuals. We are looking at broadening the newsletter’s distribution list and are continuing to develop the network of PACT/PDICI Deployment Health champions across VA to provide more points of contacts, local expertise and clinical liaisons between the field and the WRIISCs. The WRIISCs have already trained more than 30 PDICI champions from across the country to take the lead in facilitating implementation of WRIISC recommendations.
Among other efforts to ensure that primary care providers know about WRIISC, we host webinars and VeHU presentations on the functions and role of WRIISCs, and we use Community of Practice and PDICI calls to orient new team members and update training for teams over time. VA’s Office of Academic Affiliations has also developed the Military Health History Pocket Card, which has been widely distributed both within VA and to the broader medical community.
We have also realigned the Office of Public Health to work in close collaboration with Patient Care Services in VHA, which will enhance sharing of the best scientific information about the health effects of exposures with practicing clinicians.
Brown: Would the VA be willing to look at adding another WRIISC, perhaps in some place like Minneapolis? This would be a closer fit for Veterans in the Midwest, and they have top-notch research capabilities.
McDonald: VA is certainly willing to consider this request to add a new site for the WRIISCs. We share Gulf War Veterans’ enthusiasm for the fine work our VA team is doing at the three WRIISC sites: Palo Alto, Calif.; Washington, D.C.; and East Orange, N.J. Eligible Veterans with symptoms that might be deployment-related can be referred by their PCP for a comprehensive clinical evaluation at the WRIISC closest to where they live. You can find more information on the WRIISC program and how to refer patients at www.warrelatedillness.va.gov.
Brown: Can you explain the difference between DoD and VA when it comes to recordkeeping of service records on exposures that occurred during Operation Desert Storm? Many Desert Storm Veterans think that the VA sets the exposures, when in fact the VA bases their decisions on information from DoD.
McDonald: That’s true. VA does not collect exposure data. That’s not within our mandate. We rely instead on DoD for information related to deployment locations and environmental sampling of air, water and soil. VA and DoD continue to work on a project to make it easier for us to access DoD’s environmental data and estimate an individual Veteran’s exposures. We’re also still working with DoD on the Individual Lifetime Exposure Record, or ILER, which would address this question if implemented.
Brown: With all of the pilot research that has been conducted showing promise in so many different areas of Gulf War Illness research, how can we get VA to fund more follow-on research on a larger scale to verify findings from pilot studies, find our Veterans long-overdue treatments or cures, and assist them in obtaining benefits and compensation?
McDonald: VA evaluates results from pilot projects—usually involving a small number of participants—so as to plan larger studies most likely to lead to new treatments. We continue to expand our research and surveillance of Gulf War issues. For example, we’re working to expand pilot studies to multi-site studies before launching them nationwide.
Brown: How is VA’s Office of Research and Development (ORD) working with DoD to address Desert Storm Veterans’ concerns over exposures to chemical weapons as well as particulate matter and the other toxins VA has listed on its website?
McDonald: ORD and VA’s Office of Public Health (OPH) continue to work with existing VA-DoD data sharing agreements to address this issue and are always looking to establish additional new agreements when needed. DoD has developed a plan to evaluate Operation Iraqi Freedom (OIF) Veterans who were exposed to chemicals and chemical weapons, and VA subject matter experts are working with DoD as the exposed Veterans are identified. Particulates and other airborne hazards are being addressed by the Airborne Hazards and Open Burn Pit Registry, which is being coordinated by OPH. This Registry allows OIF and Operation Enduring Freedom (OEF) Veterans to register online. Veterans of Operations Desert Shield and Desert Storm are also eligible because they were deployed to the same geographic region as OIF Veterans.
Brown: For claim issues, why are not all the VA regional offices (RO) on the same page when it comes to rating claims, when all are working from the same set of laws. A better claim process at the RO level would in turn reduce the amount of claims at the Board of Veterans’ Appeals (BVA). For claims that are approved, why is it taking so long to get dependents added to claims?
McDonald: Disability claims based on Gulf War service are evaluated on a case-by-case basis under current statutes and regulations regardless of which RO is adjudicating the claim. Determining whether a claimed disability is an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI) often requires a specialized VHA medical evaluation, and variations in service-connection grants for claimed disabilities generally reflect differences in the medical or lay evidence.
In the past year, our ROs have made outstanding progress in reducing the backlog of benefit claims, shrinking the backlog by over 80 percent. It has taken a lot of overtime, but we’ve also automated much of the work, including the processing of claims for non-rating issues such as dependency. We are now using an automated rules-based processing system that improves the processing rate of dependency claims and allows claimants to submit dependency claims using eBenefits, VA’s self-service internet portal. This saves RO employees time so they can focus more on adjudicating disability claims. It also serves Veterans better and quicker. Most Veterans who submit online dependency requests receive payments in less than one day.
Brown: What can VBA do to better train ROs on Gulf War-related claims since they have such a high denial rate?
McDonald: VBA’s training and guidance to both RO and VBA quality-review personnel emphasizes a liberal approach to providing Gulf War Veterans with VHA medical staff to ensure decisions on their claims are made on the basis of the best possible medical evidence. That training and guidance is continually updated as needed to ensure that all Veterans receive consistently careful and informed consideration, including Veterans who submit Gulf War Illness disability claims.
Brown: What can be done to better train C&P examiners on chronic multiple symptoms Gulf War Veterans have since so many examiners do these exams incorrectly and do not follow Training Letter 10-01, the training guideline for raters and C&P examiners?
McDonald: First, I should explain: A denial of service connection does not mean the medical examiner has made a mistake. The physical examination is only a part of the evidence considered in determining if benefits are awarded. There are other facts to consider. For example, as stated in Training Letter 10-01, for a Veteran to qualify for disability for an undiagnosed illness, the illness must have appeared while the Veteran was in the Gulf, or it must have become at least 10 percent disabling during the applicable presumptive period. A physical examination can’t satisfy those requirements. In such cases, the submitted lay statements may be decisive.
VA provides several training courses on Gulf War and Environmental Exposure for clinicians. One is a training program called Caring for Gulf War Veterans, which is a Web-based course providing overviews of the Gulf War experience, VA and DoD programs available for Gulf War Veterans, and common symptoms and diagnoses of these Veterans. The course emphasizes the most recent information from clinical and scientific studies of Gulf War Veterans’ Illnesses to ensure clinicians are properly trained.
Caring for Gulf War Veterans is being released as a part of the Veterans Health Initiative, a comprehensive program of continuing education that recognizes the connection between certain health effects and military service, emphasizing better military medical histories for Veteran patients to provide them with the best available care.
Training is also available for various types of environmental exposure such as Agent Orange, ionizing radiation, shipboard hazards or Gulf War service.
The Office of Disability and Medical Assessment has also developed a Web-based training course on the Gulf War examination in collaboration among VBA, the Board of Veterans’ Appeals and VA’s Employee Education System. This course provides an overview of the medical examination process for Gulf War disability claims, with updated information and procedures for preparing, conducting, and documenting a C&P Gulf War general medical examination sufficient for adjudication purposes.
Brown: What steps can be taken to ensure presumptive conditions for Desert Storm Veterans under Sec 3.317 are not denied at the regional offices, which is happening now?
McDonald: The presumptive conditions associated with Gulf War service include the MUCMIs: chronic fatigue syndrome, fibromyalgia and functional gastrointestinal disorders, as well as the recently added list of infectious diseases. When these conditions are claimed, and there is sufficient evidence supporting a chronic and current disability, service connection is warranted if the required Gulf War service has been established. If there is an unresolved medical question about the presumptive condition or about whether a claimed disability is undiagnosable, VBA will obtain a medical examination or medical opinion to resolve the issue. Generally, RO denials occur when the evidence does not support the existence of a presumptive condition or undiagnosed illness.
Brown: Primary care providers are supposed to fill out disability benefits questionnaire (DBQ) forms for Veterans. Why are some not willing to doing it? And what can be done to address this matter in the different VA hospitals around the country?
McDonald: Disability examination is a central VHA mission. It is VHA policy that disability benefits questionnaires be used to provide medical evidence in support of any Veteran’s claims. (See VHA Directive 2013-002, Documentation of Medical Evidence for Disability Evaluation Purposes).
Some restrictions apply as to who can complete a DBQ. Veterans may ask their PCPs or specialists to complete a DBQ for conditions that are already diagnosed and documented and for which the PCP or specialist is treating the Veteran. DBQs can be completed during a routine office visit when there is sufficient time and the medical information is available. They can also be completed outside of an office visit, or an appointment can be scheduled for completion.
If the VHA PCP is not confident about completing a DBQ or finds the DBQ requires diagnostic testing not indicated in the history or current symptoms, the PCP must not complete the DBQ. If the PCP is not able to complete the DBQ, the PCP should discuss the reason with the Veteran and assist the Veteran in filing a claim for disability benefits. That may include directing the Veteran to the Veterans On-Line Application (VONAPP), to the VA benefits call center at 1-800-827-1000, to a Veterans service organization (VSO) representative or to other local resources. Veterans presenting to the PCP with multiple DBQs or with specialty-related DBQs may also be directed to the VONAPP, to the VA benefits call center, to a VSO representative or to other local resources. Issues related to the DBQ process should be directed to the facility director’s office or patient advocate.
Brown: We met last October to discuss the presumptive conditions the National Gulf War Resource Center (NGWRC) has been trying to have added for Desert Storm Veterans. Is there any information on these presumptive conditions you have at this time you would like to share with our Desert Storm Veterans?
McDonald: VA is committed to assisting Gulf War Veterans to the fullest extent possible under current laws and consistent with medical science. The NGWRC has suggested the inclusion of brain and lung cancers, migraine headaches, gastroesophageal reflux disease (GERD), and dyspepsia as presumptive conditions associated with Gulf War service. Dyspepsia is already considered under the MUCMI of functional gastrointestinal disorders, and service connection for GERD can be established as associated with Gulf War service where the evidence specific to a particular case supports such a finding. Regarding brain cancer, lung cancer and migraine headaches, there have been nine Institute of Medicine reports in the Gulf War and Health series since 2000, and none have provided scientific support for adding these suggested conditions to the presumptive list. As a result, they have not been added. If supporting scientific evidence becomes available in the future, VA will reconsider this decision.
Brown: The NGWRC has brought many problems and issues to you and other VA officials on behalf of our Desert Storm Veterans, but at the same time, we also provide solutions for all issues we bring forward. Can you tell our Desert Storm Veterans a little about the working relationship the NGWRC has developed with the VA?
McDonald: VA highly values our ongoing collaborative relationship with the NGWRC as we all seek to better inform and care for Gulf War Veterans. The leadership of the NGWRC has gone to great length to regularly inform VA of the issues most important to Gulf War Veterans. VA’s Spring Gulf War Newsletter is one example of this partnership
Brown: If you could tell one thing to Desert Storm Veterans or any Veterans who have lost hope in the VA, what would it be?
McDonald: I’d like them to know that this is a new day at VA, for both Gulf War Veterans and all Veterans. For Gulf War Veterans, we have a new chair of our Research Advisory Committee on Gulf War Veterans’ Illnesses – Dr. Stephen Hauser, a neuroimmunologist who chairs the department of neurology at the University of California at San Francisco.
We also have two other new committee members: Frances Perez-Wilhite, a former Army officer who served in Operation Desert Shield in 1990, and Dr. Scott Young, who was a Navy flight surgeon in the Gulf War.
For all Veterans, we have a new Secretary, new Deputy Secretary, and new Under Secretary for Health, Dr. David Shulkin, former president and CEO of Beth Israel Medical Center in New York, where he led a financial turnaround and rebuild of the $1.3 billion organization.
We are making outstanding progress on VA’s three main priorities: we’ve cut the backlog of disability claims by more than 80 percent; we’ve brought Veterans’ homelessness down by a third; and we’re providing more care to more Veterans than ever before. Ninety-seven percent of appointments are now completed within 30 days of the Veteran’s preferred date, 88 percent are within seven days and 22 percent are same-day appointments. Average wait times for completed appointments are four days for primary care, five days for specialty care and three days for mental health care.
We’ve begun a major, department-wide, transformational effort putting Veterans at the center of everything we do. We call it MyVA because that’s how we want Veterans to think of us.
The first of our five MyVA objectives is improving the Veteran experience at VA, and that starts with listening more to what Veterans say. We want to hear from Gulf War Veterans. We welcome your participation in our transformation process, and we look forward to working with you to serve all Veterans better.